By Counterforce Health Team in Filspari (sparsentan) —

How to Get Filspari (Sparsentan) Covered by Cigna in Florida: Complete Prior Authorization and Appeals Guide

Quick Answer: Getting Filspari Covered by Cigna in Florida

Fastest path to approval: Your nephrologist submits a prior authorization through CoverMyMeds with complete REMS enrollment, monthly liver function tests for year one, and documented IgAN progression risk (UPCR ≥1.5 g/g). Cigna responds within 72 hours for standard requests, 24 hours for urgent cases. If denied, you have 180 days to appeal internally, then 4 months for external review through Florida's Department of Financial Services.

Start today: Contact your prescriber to initiate REMS enrollment at filsparirems.com and gather recent kidney biopsy results, UPCR levels, and prior ACE inhibitor/ARB trial documentation.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Plan Verification
  3. Gather Required Documentation
  4. Submit Your Prior Authorization Request
  5. Follow-Up and Tracking
  6. Typical Timeline Expectations
  7. If You're Asked for More Information
  8. If Your Request Is Denied
  9. Renewal and Re-Authorization
  10. Quick Reference Checklist
  11. FAQ

What This Guide Covers

This comprehensive guide helps Florida patients with Cigna insurance navigate the prior authorization process for Filspari (sparsentan), a first-in-class medication for adults with primary IgA nephropathy (IgAN) at risk for disease progression. Whether you're facing an initial coverage request or appealing a denial, we'll walk you through each step with specific forms, timelines, and contact information for Florida residents.

Filspari carries a list price of approximately $9,900-$10,038 per 30-day supply and requires enrollment in an FDA-mandated REMS program due to hepatotoxicity risks. Understanding Cigna's specific requirements—managed through Express Scripts and Accredo specialty pharmacy—can significantly improve your chances of approval.

Before You Start: Plan Verification

Confirm Your Coverage Details

Check these basics first:

  • Plan type: Commercial, Medicare Advantage, or Medicaid managed care
  • Specialty pharmacy benefit: Filspari is typically covered under Express Scripts/Accredo specialty pharmacy
  • Formulary status: Most Cigna plans require prior authorization for Filspari
  • In-network status: Verify your prescribing nephrologist is in-network
Tip: Call the member services number on your insurance card to confirm specialty drug coverage and whether Filspari requires step therapy.

Coverage at a Glance

Requirement Details Where to Find It
Prior Authorization Required for most plans Cigna Formulary
REMS Enrollment Mandatory FDA requirement FilspariREMS.com
Specialty Pharmacy Express Scripts/Accredo Cigna Specialty Pharmacy
Liver Monitoring Monthly x12 months, then quarterly FDA Access Data
Appeal Deadline 180 days from denial Florida Insurance Code

Gather Required Documentation

Essential Clinical Information

Your nephrologist will need these documents for a complete prior authorization:

Diagnosis Documentation:

  • Kidney biopsy report confirming primary IgAN
  • ICD-10 code: N02.8 (Recurrent and persistent hematuria with other morphologic changes)
  • Current UPCR ≥1.5 g/g demonstrating progression risk
  • Recent eGFR values showing kidney function

Prior Treatment History:

  • Documentation of ACE inhibitor or ARB trial at ≥50% maximum labeled dose
  • Duration of prior therapy and clinical response
  • Any contraindications or intolerances to standard treatments

Laboratory Requirements:

  • Baseline liver function tests (ALT, AST, total bilirubin) <3x upper limit of normal
  • Recent kidney function panels
  • Urinalysis with protein quantification
Note: Cigna requires evidence that formulary alternatives have been tried or are contraindicated before approving non-formulary or step-therapy drugs.

Submit Your Prior Authorization Request

Electronic Submission (Fastest Method)

CoverMyMeds Portal (Recommended):

  1. Visit covermymeds.com/epa/express-scripts
  2. Complete immediate criteria questions
  3. Upload clinical documentation
  4. Submit REMS enrollment confirmation

Alternative Portals:

  • ExpressPAth: CareContinuum's portal for PA requests
  • MyAccredoPatients: Direct Accredo submission
  • EHR Integration: Through Surescripts if available

Required REMS Enrollment Steps

Before submitting PA:

  1. Prescriber certification: Complete at filsparirems.com
  2. Patient enrollment: Submit patient enrollment form
  3. Pharmacy certification: Ensure dispensing pharmacy is REMS-certified
  4. Monitoring plan: Establish monthly LFT schedule for first 12 months
From our advocates: "We've seen significant delays when REMS enrollment isn't completed before PA submission. Starting the REMS process early—even while gathering other documentation—can save weeks in the approval timeline."

Follow-Up and Tracking

Proactive Communication Strategy

Week 1: Confirm receipt of PA request

  • Call Cigna member services: number on your insurance card
  • Reference number from submission confirmation
  • Ask for case manager contact if available

Sample Call Script: "Hi, I'm calling to check the status of a prior authorization request for Filspari submitted on [date]. My member ID is [number] and the reference number is [if available]. Can you tell me if any additional information is needed?"

Week 2: If no decision received

  • Contact prescriber's office for peer-to-peer review request
  • Verify all documentation was received
  • Ask about expedited review if clinically urgent

Typical Timeline Expectations

Cigna Response Timeframes in Florida

Request Type Standard Timeline Expedited Timeline
Non-urgent PA 72 hours N/A
Urgent/Expedited N/A 24 hours
Internal Appeal 30 days standard, 72 hours urgent 24 hours expedited
External Review 45 days 72 hours urgent

What Speeds Decisions:

  • Complete REMS enrollment documentation
  • Clear medical necessity rationale
  • Prior therapy failure documentation
  • Electronic submission through preferred portals

What Slows Decisions:

  • Incomplete REMS enrollment
  • Missing liver function test results
  • Unclear diagnosis documentation
  • Manual fax submissions

If You're Asked for More Information

Common Medical Necessity Questions

"Why is Filspari medically necessary?"

  • Document UPCR ≥1.5 g/g indicating rapid progression risk
  • Include specialist letter explaining IgAN severity
  • Reference FDA labeling for approved indication

"Have other treatments been tried?"

  • Provide documentation of ACE inhibitor/ARB trial
  • Note any contraindications or side effects
  • Include timeline of prior therapies

Supporting Literature to Include

  • FDA prescribing information for Filspari
  • KDIGO Clinical Practice Guidelines for IgAN
  • Nephrology society position statements on IgAN treatment

If Your Request Is Denied

Common Denial Reasons & Solutions

Denial Reason How to Fix It
REMS enrollment incomplete Submit completed enrollment forms from filsparirems.com
Insufficient liver monitoring plan Provide monthly LFT schedule for year one
Medical necessity unclear Include specialist letter with progression risk documentation
Step therapy required Request step therapy exception with contraindication documentation
Quantity limit exceeded Justify dosing based on FDA labeling and patient weight

Florida Appeals Process

Internal Appeal (First Step):

  • Timeline: 180 days from denial notice to file
  • Response time: 30 days standard, 72 hours urgent
  • How to submit: Use Cigna appeal portal or mail/fax per denial letter instructions

External Review (Second Step):

  • Timeline: 4 months (120 days) from final internal denial
  • Cost: Free to consumers
  • Contact: Florida Department of Financial Services at 1-877-693-5236
  • Outcome: Binding decision on Cigna
Tip: Keep detailed records of all communications, including reference numbers, representative names, and dates. Florida's Division of Consumer Services can assist with complex appeals.

Renewal and Re-Authorization

Planning for Continued Coverage

Timing: Submit renewal requests 30-60 days before current authorization expires

Required Documentation for Renewal:

  • Updated UPCR showing treatment response or disease stabilization
  • Continued liver function monitoring results
  • No treatment-limiting adverse effects
  • Ongoing medical necessity from prescriber

Calendar Reminders:

  • Set alerts 90 days before expiration
  • Schedule nephrology appointment for renewal assessment
  • Confirm REMS enrollment remains active

Quick Reference Checklist

Before Starting Your PA Request:

  • REMS enrollment completed at filsparirems.com
  • Kidney biopsy report confirming IgAN
  • UPCR ≥1.5 g/g documented
  • Prior ACE inhibitor/ARB trial documented
  • Baseline liver function tests <3x ULN
  • Specialist letter supporting medical necessity

Submission Steps:

  • Submit via CoverMyMeds for fastest processing
  • Include all clinical documentation
  • Confirm REMS enrollment attached
  • Request expedited review if clinically urgent
  • Document submission confirmation number

If Denied:

  • File internal appeal within 180 days
  • Request peer-to-peer review
  • Contact Florida DFS at 1-877-693-5236 for external review
  • Consider Counterforce Health for complex appeals

FAQ

Q: How long does Cigna prior authorization take for Filspari in Florida? A: Standard requests receive decisions within 72 hours, urgent requests within 24 hours. Complete REMS enrollment can significantly speed the process.

Q: What if Filspari is non-formulary on my Cigna plan? A: Your doctor can request a formulary exception by demonstrating medical necessity and that formulary alternatives are inappropriate or ineffective.

Q: Can I request an expedited appeal if my initial PA is denied? A: Yes, if delay would seriously jeopardize your health. Your prescriber must document the clinical urgency in the appeal request.

Q: Does step therapy apply if I've tried other treatments outside Florida? A: Yes, prior treatment history from other states counts toward step therapy requirements. Include complete documentation from previous providers.

Q: What happens if I can't afford Filspari even with insurance coverage? A: Travere Therapeutics offers patient assistance programs. Contact their support line for eligibility information and application assistance.

Q: How often do I need liver function monitoring with Filspari? A: Monthly monitoring for the first 12 months, then every 3 months thereafter. This is an FDA requirement that cannot be waived.

Q: Can I use GoodRx or other discount programs with Cigna for Filspari? A: Specialty medications like Filspari typically must be filled through Express Scripts/Accredo. Check with your plan about copay assistance programs instead.

Q: What if my nephrologist isn't familiar with the PA process for Filspari? A: Share this guide with your provider and direct them to filsparihcp.com for prescriber resources and REMS enrollment assistance.

About Counterforce Health

Counterforce Health specializes in turning insurance denials into successful appeals for complex medications like Filspari. Our platform analyzes denial letters, identifies specific coverage criteria, and drafts evidence-backed appeals that address payers' exact requirements. For patients facing repeated denials or complex coverage situations, our targeted approach can significantly improve approval rates while saving time for both patients and providers.

Sources & Further Reading

Medical Disclaimer: This guide is for informational purposes only and does not constitute medical advice. Always consult with your healthcare provider regarding treatment decisions and insurance coverage options. Coverage policies and requirements may change; verify current information with your insurer and prescriber.

For additional assistance with insurance appeals in Florida, contact the Division of Consumer Services at 1-877-693-5236 or visit myfloridacfo.com.

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